Ob-Gyn Coding Alert

Don’t just watch for updates - be sure you select proper 4th, 5th digits

If you’ve received a denial stating the service the ob-gyn provided was “medically unnecessary,” you’ve got one problem: your diagnosis coding. Protect yourself from time-consuming appeals with these important specificity requirements.

Check for These Helpful Guides

You should always report the ICD-9 code that provides the highest degree of accuracy for the condition the ob-gyn is treating. That “highest degree” means that you should assign the most precise ICD-9 code that most fully explains the narrative description of the symptom or diagnosis.

Rely on your ICD-9 manual’s instructions to ensure you’re listing complete ICD-9 codes. If you see a check mark with a “4^th” or “5^th” next to a code, ICD-9 is telling you that the code requires a fourth or fifth digit. Anything less would result in an incomplete claim.

Example: If an ob-gyn patient who is not pregnant presents with vulvitis NOS, you’re likely going to report 616.1x (Vaginitis and vulvovaginitis). But coding shouldn’t stop there. You’ve got to add “0,” which means “vaginitis and vulvovaginitis, unspecified.” In other words, “NOS” means “not otherwise specified,” which is why 0 is the correct fifth digit.

If the patient is pregnant and has vulvitis NOS, you’ll report 646.6x (Infections of genitourinary tract in pregnancy) and add a fifth digit (0-4) to represent the current episode code such as 1 for “delivered, with or without mention of antepartum condition.”

Such careful coding is especially necessary for the ob-gyn treating a pregnant patient, because the ob-gyn is likely treating the complications of the pregnancy rather than caring for the pregnancy itself. Without the proper ICD-9 to indicate the complications, the insurer would likely rule an ob-gyn’s care incidental and part of the global ob package.

Key idea: If the ICD-9 code is not as specific as carrier rules require, the claim may be rejected for lack of medical necessity and/or a truncated code, says Margaret Lamb, RHIT, CPC, coding expert in Great Falls, Mont.

Pinpoint Possible Pitfalls

Before sending out a claim with a three-digit diagnosis code, you should double-check the code. Three-digit diagnosis codes raise payers’ eyebrows, because there are very few ICD-9 codes that don’t require at least four digits. Payers realize this fact and are examining ICD-9 codes to ensure they’re appropriately specific.

Translation: “Medically unnecessary” can often be the result of a three-digit code that didn’t make the grade because a four- or five-digit is required.

Be Specific Now to Stay Ahead of the Curve

With the ICD-10 set to go into effect in 2014, you must keep your documentation specific and your superbill updated. Many offices have quite a few truncated codes on their bills, causing coders and billers to need to go back to the chart or the physician to find out what the fourth or fifth digit should be.